Corner Stone Farm Equestrian Centre

 ENTRY FORM Corner Stone Farm Short Course Eventing

This entry is subject to the terms and conditions in the official schedule/prize list. If riding more than one horse use a new entry form for each horse entered.

Name  of Hosting Site :Corner Stone Farm  

Date of show : _______________

Rider: ____________________________   [   ] JR    [   ] SR

Address: ________________________________________________

Email:_________________________________________ 

Phone Number: _____________________

OEF # of rider _______________________ 

OEF # of owner if different ______________________________

Horse Name :________________________________________

Is the horse fully vaccinated? Yes – No –

Owner Name: ________________________________

signature of owner :_____________________________

Address:_______________________________________________

Email:________________________________

Phone Number: ___________________________________

Fees:

$ 85.00   Full Division (includes jump improvement & insurance levy)

$ 75.00   Full Division Hors Concurs (same division, same horse, different rider)

$ 65.00 'Add-on' 2nd Full Division (same horse/same rider)

$65.00 Modified with Jumping in the ring, Max height 18” but we can raise jumps higher if you prefer. MAX 2’0

$ 30.00 Dressage ONLY

$15.00 KARAT

$ 10.00 'Add-on' Dressage (each additional test)

$ 25.00 Late Fee

Divisions

(check box for all that apply) 

Modified    with Jumping in the ring, Max height 18” but we can raise jumps higher if you prefer. MAX 2’0                                     [  ] ____

Pre – Starter   up to 18" 

Dressage Only                                                                [ ] _______

(Full Division) Dressage - Cross-Country – Stadium       [ ] _______

Full Division Second Time                                             [ ] _______

Starter    up to 2’ 0" 

Dressage Only                                                                [ ] _______

(Full Division) Dressage - Cross-Country – Stadium    [ ] _______

Full Division Second Time                                             [ ] _______ 

Pre- Entry      jumps up to 2’ 6" 

Dressage Only                                                                  [ ] _______

(Full Division) Dressage - Cross-Country – Stadium      [ ] _______

Full Division Second Time                                                [ ] _______

LATE FEE - 

IF mailed less than a week before closing add this on            ($ 25.00) 

                                                                    Total fees $ _________ 

(A non-refundable administration fee of $25.00 will be applied in the case of cancellation for any reason)

Have you remembered to Include:              

 * Completed and signed  Entry?     *  Photo Copy of your OEF and the horse owners OEF?          * Payment by Cheque  /e transfer                 

Waiver signed : by rider, parent or guardian AND horse owner?   
Mail, at least ,10 days prior to closing date to insure your entry arrives in time.

ABSOLUTELY NO DOGS PERMITTED ON SHOW GROUNDS

I further grant my consent for the Representatives for the short course series and their volunteers to seek emergency medical treatment for me and/or my child if deemed necessary. By signing my name in this line I am agreeing. ___________________________

I further grant my consent for the Representatives for the short course series and their volunteers  for me/ or my child ,  any image or likeness to be used for promotional purposes in print media or other.       By signing my name in this line I am agreeing. ____________________ OR circle  DECLINED

Emergency contact Relationship to rider : _____________________   Date: ________    

Short Course Event Series: Kingston    (  Please Print clearly  ) ACKNOWLEDGMENT of RISK and RELEASE of LIABILITY “For All Participants -Guardians must fill out for the Rider under age”    Participant (or Infant Participant ) ’s    

Name:                                          Date of Birth: ______________       Rider Address: _________   Email:__________________________________________

If under 18 yrs old Guardian’s  Name: ______________________ Phone: ____________________

Guardian’s Address: ________________________________________Date of Birth: Have you (the participant or participant guardian) ever filed a personal lawsuit? YES / NO  (please circle)   

The Guardian or Participant must Read and Understand prior to the Infant Participating in Equine Activities TO: SHORT COURSE EVENTING and the host site  Corner Stone Farm, Catherine Colwell and Joseph McAllister ________________________________ their directors, employees, officers. (Name of Person, Organization or Company providing the Equine Activities) volunteers, business operators, and site property owners. (all of them collectively called the HOST)

Initial each item below After Reading and Understanding the item 

____I hereby release and absolve the Organizing Committee, Volunteers, Officers, Directors, Agents, Representatives and employees, independent contractors and the owners.

___ I am the Rider or the Parent and/or Legal Guardian of the infant Participant named above and am executing this form on behalf of the infant Participant in my capacity as parent and/or guardian and with the intent that this form be binding on myself and infant Participant for all legal purposes.

____1 Understand there are Inherent DANGERS, HAZARDS and RISKS, (collectively called RISKS) associated with Equine Activities and injuries resulting from these “RISKS” are a common occurrence.

____ I Acknowledge that the Inherent “RISKS” of Equine Activities mean those DANGEROUS conditions which are an integral part of Equine Activities, including but not limited to: • The propensity of any equine to behave in ways that might result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people, or objects. • The unpredictability of an equine’s reaction to such things as sounds, sudden movement, tremors, vibrations. unfamiliar objects, persons or other animals and hazards such as subsurface objects. • The potential for other participant (s) to act in a negligent manner that might contribute to injury to themselves or others, such as failing to act within their ability or to maintain control over an equine.

____I Freely Accept and Fully Assume All Responsibility for the Inherent “RISKS” and the possibility of personal injury, death, property damage or loss which might result from myself/the infant being a Participant.

____ I Acknowledge that it remains my Sole Responsibility for the safety of myself/the infant Participant and for myself/the infant to Participate within his/her own limits.

_____In addition to consideration given for myself/the infant to Participate in Equine Activity, I and my heirs, executors, administrators and assigns (my “Legal Representatives”) agree • To Waive All Claims that I or the infant Participant might have against the “HOST”; and To Release the “HOST” from Any and All Liability for any loss, damages, injury, or expense that I, the infant Participant or our “Legal Representatives” might suffer as a result of Participation due to any cause including any NEGLIGENCE ON THE PART OF THE “HOST”: and to HOLD HARMLESS AND INDEMNIFY THE “HOST” from any and all liability for property damage or personal injury to myself/the infant Participant or to a third party which might result from Participation.

Before signing this form I read it (as indicated by my initials above) and I stated that I understand it. I further state I am aware that signing this form, waives certain legal rights I and/or the infant Participant and/or our “Legal Representatives” might have against the “HOST”.

SIGNED This ______________ day   of_________________ 2015.

(Signature Host Witness)

Corner Stone Farm , Catherine Colwell and Joseph McAllister 

(Print Name of HOST Witness to signing & Initialing) __________________________

Do Not Sign until you Understand All Items Above